Financial Barriers Impede Care After Acute MI

Action Points

Explain to interested patients that patients with financial barriers to health care and medications after a heart attack may have a poorer quality of life and a higher risk of re-hospitalization.

Explain to patients who ask that insurance coverage, where it existed, may not have been adequate.

NEW HAVEN, Conn., March 13 -- Patients who could not afford health-care services or medications after an acute myocardial infarction had a worse recovery, more angina, and an increased rate of re-hospitalization, researchers reported.

About one in five acute MI patients reported having financial barriers to health care services, Harlan Krumholz, M.D., of Yale, and colleagues, reported in the March 14 issue of the Journal of the American Medical Association, a theme issue on access to health care.

Furthermore, one in eight patients could not afford medications, even though almost 70% of the patients in the study were insured, although perhaps not adequately, found Dr. Krumholz and colleagues.

In the study that followed 2,498 patients with acute MI from 2003 to 2004, 18.1% reported financial barriers to health care services, while 12.9% had trouble affording their medications, the researchers found.

The patients were enrolled in the Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER), a 12-month observational, multicenter U.S. study of patients with acute MI.

The findings were based on self-reported financial barriers to health care services or medications (defined as avoidance due to cost). Health status symptoms were evaluated on the Seattle Angina Questionnaire (SAQ), overall health status function (Short Form-12), and re-hospitalization.

Among those who reported financial barriers to health care services or medication, 68.9% and 68.5% respectively were insured, the researchers reported. Since insurance coverage alone does not eliminate financial barriers to health care, in this study the researchers chose to measure self-reported avoidance of health care due to cost, they said.

At one-year follow-up, only 66.2% of those with financial barriers experienced good-to-excellent quality of life compared with 86.8 % of those without the barrier. As a result the mean SAQ and SF-12 scores remained significantly lower for those with financial barriers (P<0.001).

There were substantial differences in the baseline characteristic of those who reported financial barriers to health-care services, the researchers said. These patients were more likely to be younger than 65, female, and nonwhite. Additionally, they were more likely to have less education, no insurance, and to live with less income than their counterparts.

There was concern that the differences in post-acute MI outcomes might have been due to potential differences in in-patient care between the two study populations. However a secondary analysis of in-patient care that controlled for coronary angiography and revascularization, for example, did not change the study's findings, the researchers said.

Issues to be considered in interpreting this study, according to the investigators, include the fact that self-reported financial barriers, although reported at baseline, were not reported at one year.

In addition, the study may not be generalizable to the entire U.S. population, particularly to rural groups. Even though the study included a diverse set of sites, there is significant inter-hospital variability in the type and quality of care delivered by U.S. hospitals, which this study may not have reflected adequately.

In summary, the researchers wrote, "Financial barriers to health care are a common and potent risk factor in the AMI population."

They went on to note that these barriers are prominent even in individuals with health insurance, suggesting underinsurance.

"There is a need to develop approaches that will mitigate this increased risk and address this barrier to care and medications," Dr. Krumholz's team concluded.

This research was funded in large part by Cardiovascular Therapeutics of Palo Alto, Calif.; Cardiovascular Outcomes of Kansas City,; and the National Heart, Lung, and Blood Institute. Dr. Krumholz reported that he was a consultant for Cardiovascular Therapeutics Inc. Co-author John Spertus, M.D., reported that he received a research grant from Cardiovascular Therapeutics, and was a consultant for that company. Susannah Bernheim, M.D., was a fellow in the Robert Wood Johnson Clinical Scholars Program during the time this work was conducted.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

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